Radiology Coding Alert

Question: The radiologist documented an ultrasound-guided aspiration of right upper quadrant perihepatic fluid collection. "A 20-gauge needle was advanced into the perihepatic fluid collection with difficulty. A wire could not be passed into this collection raising the suspicion that the collection may be in part solid. A 5 French catheter was placed. A few drops of bile appearing material was aspirated. Therefore, a wire was passed into the collection and a 6.5 French drain was placed. The catheter was placed to gravity drainage. Less than 1 cc of bilious fluid could be aspirated and was sent for culture and bilirubin." Should I report 49020 and 75989?

Texas Subscriber

Answer: Your best bet is to report 49021 (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; percutaneous) because the catheter was left indwelling.

You may report the ultrasound guidance separately using 75989 (Radiological guidance [i.e., fluoroscopy, ultrasound, or computed tomography], for percutaneous drainage, e.g., abscess, specimen collection], with placement of catheter, radiological supervision and interpretation).

Tip: Code 49020 (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open) would not be correct for this case because 49020 describes an open procedure, and the use of ultrasound guidance and a needle indicates a percutaneous procedure.